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Effect of correction surgery for cervical kyphosis on compensatory mechanisms in overall spinopelvic sagittal alignment

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Progression of kyphotic deformity at the middle/lower cervical spine can cause difficulty with horizontal gaze, so compensation at other spinopelvic parts may occur. However, the precise mechanism remains unclear. The present study investigated the effect of correction surgery for cervical kyphosis on the compensatory mechanisms in overall spinopelvic sagittal alignment.


Forty-one patients, comprising 23 males and 18 females (mean age 67 years), underwent correction surgery for cervical kyphosis using the posterior screw–rod system. Spinopelvic lateral radiographs in the standing position were taken before and after surgery. C0–1 angle, C1–2 angle, clivo-axial angle (CAA), C2–7 angle, thoracic kyphosis, lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope were measured. Correlations between C2–7 angle and these parameters before surgery, and correlations between the correction angle of cervical kyphosis and postoperative changes of these parameters were evaluated.


Negative correlations were found between the C2–7 angle and CAA (R = −0.640, p < 0.01), and C2–7 angle and C0–1 angle (R = −0.762, p < 0.001) before surgery. Negative correlations were found between the correction angle of C2–7 and change of CAA (R = −0.718, p < 0.001), and between the correction angle of C2–7 and change of C0–1 angle (R = −0.672, p < 0.01) after surgery.


The present study demonstrated that C0–1 angle and CAA are more important in the compensatory mechanism for kyphotic deformity at the middle/lower cervical spine compared to downward parameters. That is, to maintain horizontal gaze, lordosis increases at the cranio-cervical junction with greater kyphosis at the middle/lower cervical spine. Correction of cervical kyphosis in the middle/lower cervical spine resulted in normalization of the C0–1 angle and CAA because the compensatory mechanism at the cranio-cervical junction for obtaining horizontal gaze was no longer necessary after surgical intervention.

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  1. Mihara H, Ohnari K, Hachiya M, Kondo S, Yamada K (2000) Cervical myelopathy caused by C3–C4 spondylosis in elderly patients: a radiographic analysis of pathogenesis. Spine (Phila Pa 1976) 25(7):796–800

    Article  CAS  Google Scholar 

  2. Diebo BG, Varghese JJ, Lafage R, Schwab FJ, Lafage V (2015) Sagittal alignment of the spine: what do you need to know? Clin Neurol Neurosurg 139:295–301

    Article  PubMed  Google Scholar 

  3. Schwab F, Ungar B, Blondel B, Buchowski J, Coe J, Deinlein D et al (2012) Scoliosis research society-Schwab adult spinal deformity classification: a validation study. Spine (Phila Pa 1976) 37:1077–1082

    Article  Google Scholar 

  4. Yoshimoto H, Ito M, Abumi K, Kotani Y, Shono Y, Takada T, Minami A (2004) A retrospective radiographic analysis of subaxial sagittal alignment after posterior C1–C2 fusion. Spine (Phila Pa 1976) 29(2):175–181

    Article  Google Scholar 

  5. Inada T, Furuya T, Kamiya K, Ota M, Maki S, Suzuki T, Takahashi K, Yamazaki M, Aramomi M, Mannoji C, Koda M (2016) Postoperative increase in occiput-C2 angle negatively impacts subaxial lordosis after occipito-upper cervical posterior fusion surgery. Asian Spine J 10(4):744–747. doi:10.4184/asj.2016.10.4.744 (Epub 2016 Aug 16)

    Article  PubMed  PubMed Central  Google Scholar 

  6. Lee DH, Ha JK, Chung JH, Hwang CJ, Lee CS, Cho JH (2016) A retrospective study to reveal the effect of surgical correction of cervical kyphosis on thoraco-lumbo-pelvic sagittal alignment. Eur Spine J 25(7):2286–2293

    Article  PubMed  Google Scholar 

  7. Miyamoto H, Maeno K, Uno K, Kakutani K, Nishida K, Sumi M (2014) Outcomes of surgical intervention for cervical spondylotic myelopathy accompanying local kyphosis (comparison between laminoplasty alone and posterior reconstruction surgery using the screw-rod system). Eur Spine J 23(2):341–346

    Article  PubMed  Google Scholar 

  8. Corbett JJ, Butler AB, Kaufman B (1976) ‘Sneeze syncope’, basilar invagination and Arnold–Chiari type I malformation. J Neurol Neurosurg Psychiatry 39(4):381–384

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Horton WC, Brown CW, Bridwell KH, Glassman SD, Suk SI, Cha CW (2005) Is there an optimal patient stance for obtaining a lateral 36″ radiograph? A critical comparison of three techniques. Spine (Phila Pa 1976) 30:427–433

    Article  Google Scholar 

  10. McRae DL, Barnum AS (1953) Occipitalization of the atlas. Am J Roentgenol Radium Ther Nucl Med 70(1):23–46

    CAS  PubMed  Google Scholar 

  11. Shimizu K, Nakamura M, Nishikawa Y, Hijikata S, Chiba K, Toyama Y (2005) Spinal kyphosis causes demyelination and neuronal loss in the spinal cord: a new model of kyphotic deformity using juvenile Japanese small game fowls. Spine (Phila Pa 1976) 30(21):2388–2392

    Article  Google Scholar 

  12. Suda K, Abumi K, Ito M, Shono Y, Kaneda K, Fujiya M (2003) Local kyphosis reduces surgical outcomes of expansive open-door laminoplasty for cervical spondylotic myelopathy. Spine (Phila Pa 1976) 28(12):1258–1262

    Google Scholar 

  13. Suarez GA, Kelly JJ Jr (1992) The dropped head syndrome. Neurology 42:1625–1627

    Article  CAS  PubMed  Google Scholar 

  14. Tang JA, Scheer JK, Smith JS, Deviren V, Bess S, Hart RA et al (2012) The impact of standing regional cervical sagittal alignment on outcomes in posterior cervical fusion surgery. Neurosurgery 71:662–669

    Article  PubMed  Google Scholar 

  15. Richman JD, Daniel TE, Anderson DD, Miller PL, Douglas RA (1995) Biomechanical evaluation of cervical spine stabilization methods using a porcine model. Spine (Phila Pa 1976) 20(20):2192–2197

    Article  CAS  Google Scholar 

  16. Singh K, Vaccaro AR, Kim J, Lorenz EP, Lim TH, An HS (2003) Biomechanical comparison of cervical spine reconstructive techniques after a multilevel corpectomy of the cervical spine. Spine (Phila Pa 1976) 28(20):2352–2358

    Article  Google Scholar 

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Correspondence to Hiroshi Miyamoto.

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Miyamoto, H., Hashimoto, K., Ikeda, T. et al. Effect of correction surgery for cervical kyphosis on compensatory mechanisms in overall spinopelvic sagittal alignment. Eur Spine J 26, 2380–2385 (2017).

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